| NPI | 1861866899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005532) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12305) |
| Enumeration Date | 2015-11-13 |
| Last Update Date | 2022-03-02 |